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NPI Code Detail

MEDICARE: ANDREW T DOHERTY PA-C

MEDICARE: ANDREW T DOHERTY PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant085.003763IL

General Provider Information

NPI Number : 1962716456
Entity Type Code : Individual
Provider Name (Legal Business Name) : ANDREW T DOHERTY PA-C
Provider Business Mailing Address
First Line : 713 SUNGLOW CT
Second Line :
City : DEKALB
State : IL
Zip : 60115-8585
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 3475 S ALPINE RD
Second Line :
City : ROCKFORD
State : IL
Zip : 61109-2604
Country : US
Telephone Number : 815-874-8000
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/27/2010
Last Update Date : 04/04/2016

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Directions to “ ANDREW T DOHERTY PA-C” Practice Location

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